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Shoulder and Shoulder Girdle: Anatomy and Function

The anatomy and function of the shoulder girdle

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SHOULDER AND SHOULDER GIRDLE Orthopedic and Sports 2
The shoulder region is a complex of 20 muscles, three bony articulations, and three soft tissue moving surfaces (functional joints) that permit the greatest mobility of any joint area found in the body. The primary purpose of the shoulder is to put the hand in a position for function
STRUCTURE AND FUNCTION
BONES
MANUBRIUM (STERNUM) Secures the upper extremity to the axial skeleton Superior: Sternal notch or jugular notch Lateral: Clavicular facets (attachment of the first rib)
CLAVICLE Strut bone – lateral strut to the scapula and humerus S-shaped, with forward convexity at the sternal end (to clear the brachial plexus & UE vascular bundle) and forward concavity at the humeral/acromial end Resting 20° to the frontal plane
SCAPULA Flat, triangular-shaped bone 5-6 cm/2-3 finger-width from the spinous processes Landmark: T2-T7 spinous process Dual function: (1) attachment of muscles controlling the GH joint, and (2) provide stable base from which the GH joint can function
HUMERUS Head of the humerus forms the GH jt with the glenoid fossa. 1/3 or ½ of a sphere Humeral head
JOINTS
SCAPULOTHORACIC JOINT A functional joint BUT Not A “TRUE JOINT” Functions: Increase the ROM of the shoulder (greater reach) Maintain favorable length-tension relationship for the deltoid muscle to function above 90º of GH elevation Provide GH stability through maintained glenoid and humeral head alignment Providing injury prevention through shock absorption of forces applied to the outstretched arm Permitting elevation of the body in activities (assistive device and transfers)
SCAPULOTHORACIC JOINT ST Joint Kinematics  Scapular Elevation/Depression  Scapular Protraction/Retraction  Scapular Upward Rotation/Downward Rotation
SCAPULOTHORACIC JOINT Scapulothoracic Rhythm Phase Humerus Scapula Clavicle I 30º Abduction Setting Phase 0-5º Elevation II 40º Abduction 20º Upward rotation 10-15º Elevation III 60º Abduction 30º Upward rotation Clavicle starts to rotate posteriorly
GLENOHUMERAL JOINT Ball-and-socket joint; Spheroid jt; Universal Joint Degrees of freedom: 3 DOF Little bony stability Articulation: Convex humeral head – Concave glenoid fossa (shallow, inclined) Joint relies on the surrounding soft tissue supports for stability  Mobile, however, is at the expense of structural stability
GLENOHUMERAL JOINT Open-Packed Position 40° to 55° abduction, 30° horizontal adduction (scapular plane) Closed-Packed Position Full abduction, lateral rotation Capsular Pattern Lateral rotation, abduction, medial rotation
GLENOHUMERAL JOINT Ligaments Ligament Position of Greatest Jt Protection Motion it Limits Coracohumeral ligament With arm at the side Limits excessive lateral rotation Limits inferior translation of humeral head Superior GH ligament With arm at the side (0-45º) Limits anterior and inferior translation of the humeral head Middle GH ligament With the arm at the side and lower levels (up to about 45°) of abduction Limits anterior translation and lateral rotation of the humeral head Inferior glenohumeral ligament Higher levels of abduction (above 45°), with or without rotation Higher levels of abduction (above 45°), with or without rotation Anterior fibers - limit anterior humeral head translation during abduction and lateral rotation Posterior fibers - limit posterior humeral head translation during abduction and medial rotation Inferior fibers - limits abduction at 90° and provides AP All normal limitations of motion on the glenohumeral joint are due to ligamentous and passive muscle tightening. Thus, the end feels are all firm.
GLENOHUMERAL JOINT Coracoacromial arch  Osteoligamentous arch, formed by the coracoacromial ligament, that serve as the roof to the GH joint Subacromial space  Space between the coracoacromial arch and the GH joint  Supraspinatus muscle and tendon  Long head of the biceps tendon  Subacromial bursa  Superior capsule
GLENOHUMERAL JOINT Bursae Bursa reduces friction between two structures  Subacromial bursa  Subdeltoid Bursa
GLENOHUMERAL JOINT MUSCLE GH Joint Kinematics  Flexion-extension  Abduction-adduction  Medial rotation-lateral rotation GH Joint Arthrokinematics
STERNOCLAVICULAR JOINT Type of joint: Saddle joint, Sellar joint Degrees of freedom: 3 DOF Articulation:  Medial end of clavicle  Manubrium
STERNOCLAVICULAR JOINT Open-Packed Position Arm at side Closed-Packed Position Full elevation and protraction Capsular Pattern Pain at extremes of ROM, especially horizontal adduction and full elevation
STERNOCLAVICULAR JOINT Ligament Motion it limits Anterior SC ligament Limits posterior displacement of clavicle Posterior SC ligament Limits anterior displacement of clavicle Superior SC ligament Interclavicular ligament Limits upward clavicular displacement Costoclavicular ligament Limits clavicular elevation, rotation, and medial and lateral movements
SC JOINT Kinematics  3 DOF  Elevation/depression (30-45º/5-10º)  Protraction/retraction (15-30º)  Rotation  Posterior rotation (40-50º) – passive motion  Occurs after 90º of elevation  (-) rotation  arm motion is limited to 110º Arthrokinematics
ACROMIOCLAVICULAR JOINT Type of joint: Plane Synovial Joint Degrees of Freedom: 3 DOF Articulation:  Acromion process  Lateral end of Clavicle
ACROMIOCLAVICULAR JOINT Open-Packed Position Arm at side Closed-Packed Position 90º abduction Capsular Pattern Pain at extremes of ROM, especially horizontal adduction and full elevation
ACROMIOCLAVICULAR JOINT Ligaments Ligament Motion it limits Posterior AC ligament Limits superior translation of the distal clavicle Superior AC ligament Limits inferior translation of the distal Coracoclavicular ligament • Trapezoid – restricts superior translation of the distal clavicle (1ry) • Conoid – prevents medial displacement of the sacpula
ACROMIOCLAVICULAR JOINT AC Joint Kinematics  3 DOF of Scapular Movements  Elevation/depression  Abduction/adduction  Upward/Downward rotation Primary function at the AC joint is to allow the scapula to maintain contact with the thorax throughout its movement by providing slight adjustments in the scapular motions provided via the sternoclavicular joint.
SHOULDER GIRDLE FUNCTION
SCAPULOHUMERAL RHYTHM Upward rotation, posterior tilting and scapular external rotation w/ shoulder elevation Synchronous motion of scapula allows the muscle moving the humerus to maintain an effective length-tension relationship and helps maintain congruency while decreasing shear forces. Upper and lower trapezius and serratus anterior creates upward rotation of the scapula. Pectoralis minor lengthening allows scapula to rotate upward, retracts, and tip posteriorly.
CLAVICULAR ELEVATION AND ROTATION WITH HUMERAL MOTION First 30º of upward rotation of the scapula occurs at the SC jt. Tightening of coracoclavicular ligament, rotates the clavicle and elevates the acromial end  additional 30º of upward rotation at AC jt.
EXTERNAL ROTATION OF HUMERUS WITH ELEVATION Humerus externally rotates to allow clearance of greater tubercle to the acromion/coracoacromial arch.
DELTOID-SHORT ROTATOR CUFF AND SUPRASPINATUS Deltoid – upward translation of the humerus, and if unopposed, it leads to impingement of soft tissues in the subacromial space. In order to prevent it,  Infraspinatus, teres minor, and subscapularis (ITS) produces stabilizing compression and downward translation of the humerus  Deltoid and ITS actions  balance forces that elevate the humerus and control humeral head  Supraspinatus has significant stabilizing, compressive, and slight upward translation.  Interruption of the coordinated function may lead to tissue microtrauma and shoulder complex dysfunction.
REFERRED PAIN AND NERVE INJURY Common Sources of Referred Pain in the shoulder  Cervical Spine  C3-C4 or C4-C5 segments  C4 or C5 nn roots  Referred pain  C4 dermatome  Trapezius  tip of the shoulder  C5 dermatome  Deltoid region and lateral arm  Diaphragm: Pain at the upper trapezius shoulder region  Heart: Pain at the left axilla and pectoral region  Gallbladder: Pain at the tip of the shoulder and scapular region
SHOULDER CONDITIONS/DISORDERS AND MANAGEMENT
JOINT HYPOMOBILITY: NON- OPERATIVE MANAGEMENT
GH JOINT ARTHRITIS
GH JOINT ARTHRITIS Acute Phase Pain, muscle guarding, limited ER & Abd. Pain radiates to the elbow Sleep disturbance Tenderness is elicited by palpating in the sulcus Subacute Phase Chronic Phase Capsular tightness (ERABIR), limited joint play Pain at end of range Progressive GH joint capsule restriction Loss of function Pain localized at deltoid region
IDIOPATHIC FROZEN SHOULDER Stage Duration Characteristics Stage 1 Pre-freezing <3 months Gradual onset of pain with movement and persistent at night Loss of ER motion Intact rotator cuff strength Stage 2 Freezing 3-9 months Persistent and more intense pain at rest Motion is limited in all direction (-) restoration from intra-articular injections Stage 3 Frozen 9-15 months Pain on movement Significant adhesions  LOM Excessive scapulothoracic movement Atrophy: deltoid, rot cuff, biceps, and triceps Stage 4 Thawing 15-24 months Minimal pain Significant capsular restrictions Gradual improvement of motion Some never regain normal ROM
COMMON IMPAIRMENTS OF STRUCTURE AND FUNCTIONS Night pain and disturbed sleep during acute flares Pain on motion and often at rest during acute flares Mobility: decreased joint play and ROM, usually limiting external rotation and abduction with some limitation of internal rotation and flexion Posture: possible faulty postural compensations with protracted and anteriorly tilted scapula, rounded shoulders, or guarding the painful shoulder in a position of scapula elevation and arm adduction
COMMON IMPAIRMENTS OF STRUCTURE AND FUNCTIONS Decreased arm swing during gait Muscle performance: general muscle weakness and poor endurance in the GH muscles with overuse of the scapular muscles leading to pain in the trapezius, levator scapulae, and posterior cervical muscles Increased scapulothoracic motion during arm movements to compensate for limited GH mobility
COMMON ACTIVITY LIMITATIONS AND PARTICIPATION RESTRICTIONS Inability to reach overhead, behind head, out to the side, and behind back leading to difficulty dressing (putting on a jacket or coat or in the case of women, fastening undergarments behind their back), reaching hand into back pocket of pants (to retrieve wallet), reaching out a car window (to use an ATM machine), self-grooming (combing hair, brushing teeth, washing face), and bringing eating utensils to the mouth Difficulty lifting heavy objects above shoulder level Limited ability to sustain repetitive activities
MANAGEMENT: PROTECTION PHASE Educate the Patient  Activity modifications, stages of healing, Control Pain, Edema, and Muscle Guarding  Immobilization, passive or assisted motion, oscillation techniques, tissue mobilization
MANAGEMENT Maintain Soft Tissue and Joint Integrity and Mobility  PROM (pain free), Grade I-II distraction and glides, pendulum exercises, gentle muscle setting Maintain Integrity and Function of Associated Regions  Prevent complications by adding hand exercises, keep distal joints active and mobile, (+) edema  hand elevation, and ROM, mobilization of the cervical region
MANAGEMENT: CONTROLLED MOTION PHASE Control Pain, Edema, Joint Effusion  Functional activities, ROM Progressively Increase Joint and Soft Tissue Mobility  Passive joint mobilization techniques (grade III sustained or grade III and IV oscillations), self- mobilization techniques, manual stretching, self-stretching exercises Inhibit Muscle Spasm and Correct Faulty Mechanics  Grade I and II oscillation, sustained caudal glide joint techniques, protected weight bearing, IR/ER strengthening, movement retraining
MANAGEMENT: CONTROLLED MOTION PHASE Improve Joint Tracking  Shoulder mobilization with movement Improve Muscle Performance  Manual techniques, stretches, and strengthening exercises are initiated to correct muscle length or strength imbalances, followed by an emphasis on developing active control of weak musculature.  Exercises to manage faulty spinal posture.  Active ROM of all shoulder motions daily and return to functional activities to the extent tolerated.
MANAGEMENT: RETURN TO FUNCTION Progressively Increase Flexibility and Strength  Stretching and strengthening exercises, as tolerated  Emphasis of treatment is on maintaining correct mechanics, safe progressions, and exercise strategies for return to function.  (+) capsular restriction  vigorous manual stretching and joint mobilization Prepare for Functional Demands  Exercises must and are progressed to replicate these demands (work, sports, etc.)
AC AND SC JOINT PATHOLOGIES Pathologies Etiology of Symptoms Overuse Syndrome Repeated stressful joint movements or repeated diagonal extension, adduction, and IR Subluxation or Dislocation FOOSH  overstretching of ligament  permanent joint hypermobility Hypomobility Decreased clavicular mobility may occur with SC joint OA and may contribute to TOS by compromising the space available for the neuromuscular bundle as it courses between the clavicle and first rib
COMMON IMPAIRMENTS OF STRUCTURE AND FUNCTION Pain localized to the involved joint or ligament. Painful arc toward the end-range of shoulder elevation. Pain with shoulder horizontal adduction or abduction. Hypermobility if trauma or overuse is involved. Hypomobility if sustained posture, arthritis, or immobility is involved.
COMMON ACTIVITY LIMITATIONS AND PARTICIPATION RESTRICTIONS Limited ability to sustain repeated forceful movements of the arm, such as with grinding, packing, assembly, and construction work Inability to reach overhead or perform repetitive overhead activities without pain.
NONOPERATIVE MANAGEMENT OF AC OR SC JOINT STRAIN OR HYPERMOBILITY Minimize joint loading by supporting the weight of the arm with a sling. Cross-fiber massage to the capsule or ligaments. Maintain ROM of the GH joint and scapulothoracic articulation. Instruction in self-application of cross-fiber massage if joint symptoms occur after excessive activity. Increase strength of shoulder complex, trunk, and legs. Gradually return to functional activities.
GLENOHUMERAL JOINT SURGERY AND POSTOPERATIVE MANAGEMENT
GOALS OF THE SURGICAL PROCEDURE Relieve pain Improve shoulder mobility or stability Restore or improve strength and functional use of the upper extremity.
Total Shoulder Arthroplasty (TSA) Reversed TSA Hemiarthroplasty (+) loss or thinning of the articular cartilage of the head of the humerus and the posterior portion of the glenoid fossa. (+) Chronic deficiency of the rotator cuff mechanism. (+) deterioration of the articular surface and underlying bone of the humeral head, but glenoid fossa is intact. Intact rotator cuff (90-95%)
GLENOHUMERAL ARTHROPLASTY Implant design, materials, and fixation  Unconstrained design  MC used | Small, shallow glenoid component | Greatest freedom | Indicated when Rot, Cuff is intact or can be repaired  Semiconstrained  Large glenoid component that is hooded or cup-shaped | Some degree of stability | Indicated when erosion of scapula can be compensated by reaming the fossa | Functional rot cuff  Reverse ball and socket  Small humeral socket that slides on a larger ball-shaped glenoid component | Moderate stability with rot cuff mobility | Alternative approach  Constrained  Fixed fulcrum, ball and socket designs | Greatest stability, dec mobility | Rarely
SHOULDER ARTHROPLASTY PROCEDURE Anterior approach using a deltopectoral incision that extends from the AC joint to the deltoid insertion for adequate surgical exposure. Release (tenotomy) of the subscapularis tendon from its proximal attachment on the lesser tuberosity. Anterior capsulotomy Exposure of the humeral head for a humeral osteotomy Preparation of the humeral canal for insertion of the prosthetic implant. Glenoid fossa is either débrided or contoured Reattachment of subscapularis mm
COMPLICATIONS TSA complications are low Incidence tends to be higher in patients with deficient rotator cuff mechanism
POSTOPERATIVE MANAGEMENT The goals, components, and rate of progression are influenced by the preoperative and postoperative integrity of the rotator cuff mechanism.  Progression of intact rotator cuff > rotatory cuff w/ deficiency Intraoperative ROM determines the goals for safe, stable postoperative ROM. Emphasize an erect sitting or standing posture during elevation of the arm.
POSTOPERATIVE MANAGEMENT Immobilization and Postoperative Positioning  (+) rotator cuff repair or soft tissue reconstruction – wear shoulder sling for 4-6 weeks
POSTOPERATIVE MANAGEMENT Exercise progression  TSA  Phase 1: Weeks 0-4  Phase 2: Weeks 4-12  Phase 3: Weeks 12+  rTSA  Phase 1: Weeks 0-6  Phase 2: Weeks 6-12 or 16  Phase 3: Weeks 12+ or 16+ Table 17.2 Comparison of Exercise Guidelines and Precautions Following TSA and rTSA
MAXIMUM PROTECTION PHASE (0 TO 4/6 WEEKS) Patient education, pain control and initiation of ROM Goals and Interventions  Control pain and inflammation  Sling or splint, analgesics and anti-inflammatory medications, cryotherapy after exercise  Maintain mobility of adjacent joints  Active ROM (AROM) spine, scapular, hand, wrist and elbow  Restore shoulder mobility  PROM (scapular plane elevation), pendulum exercises, progress: self-assisted shoulder ROM, self-assisted reaching movements | by 4 weeks active shoulder ROM  Minimize muscle inhibition, guarding, & atrophy  Gentle ms setting, scapular stabilization (NWB, target traps and SA)
MAXIMUM PROTECTION PHASE (0 TO 4/6 WEEKS) Criteria for progress  ROM  At least: 90º passive elevation, 45º ER, and 70º IR in the plane of scapula  Pain  No pain during resisted, isometric internal rotation  Skill  Ability to perform waist-level ADLs without pain  rTSA  Tolerance of assisted ROM, ability to isometrically activate deltoid and periscapular muscles @ scapular plane.
MODERATE PROTECTION PHASE (4/6 TO 12/16 WEEKS) Focuses on gradually establishing active (unassisted) control, dynamic stability, and strength of the shoulder while continuing to increase ROM. Goals and Intervention  Continue to increase shoulder ROM  Develop active control and dynamic stability and improve performance of the shoulder  Pain free, low-intensity resisted isometrics of shoulder muscles  Dynamic resistance exercises for the scapula and shoulder muscles (0-90º elevation, supine  sitting).  UE endurance training
MODERATE PROTECTION PHASE (4/6 TO 12/16 WEEKS) Criteria to Progress  Full, passive ROM of the shoulder (intraoperative ROM) or pain-free passive or assited shoulder flexion to 130- 140º and abd of 120º  60º ER and 70º IR in the plane of scapula  Active, antigravity elevation of the arm to at least 100° to 120° in the plane of the scapula  Deltoid: grade 4/5 MMT
MINIMUM PROTECTION PHASE (12+ OR 16+ WEEKS) Focuses on pain-free strengthening of the shoulder muscles for dynamic stability and functional use of the upper extremity for progressively more demanding tasks. Goals and Intervention  Continue to improve or maintain shoulder mobility  End-range self-stretching | Grade III joint mobilization | Self-mobilization  Continue to improve neuromuscular control and muscle performance of the shoulder  Pain-free, low-load, high-repetition progressive resistive exercise | Replicate functional tasks | Closed chain, restricted shoulder exercises | Lifting, carrying, pushing or pulling activities  Return to most functional activities  Use UE for more advanced functional activities | Swimming, golf (recreational activities) | Activity modification, especially on high- demand/-impact activities
PAINFUL SHOULDER SYNDROMES (ROTATOR CUFF DISEASE AND TENDINOPATHIES): NONOPERATIVE MANAGEMENT
RELATED PATHOLOGIES AND ETIOLOGY OF SYMPTOMS Intrinsic Impingement  Rotator Cuff Extrinsic Impingement  Mechanical Compression  Primary extrinsic impingement  E.g. Acromial variations  Secondary intrinsic impingement  Hypermobility or instability  Internal extrinsic impingement  Throwing athletes shoulder position impinge supraspinatus tendon bet head and labrum
RELATED PATHOLOGIES AND ETIOLOGY OF SYMPTOMS Tendonitis  Supraspinatus tendonitis  Infraspinatus tendonitis  Bicipital tendonitis  Bursitis
COMMON IMPAIRMENTS OF STRUCTURE AND FUNCTION Impaired posture and muscle imbalances Decreased thoracic range of motion Rotator cuff overuse and fatigue Weakness secondary to neuropathy Hypomobile posterior GH joint capsule
COMMON ACTIVITY LIMITATIONS AND PARTICIPATION RESTRICTIONS In the acute stages, pain may interfere with sleep, particularly when rolling onto the involved shoulder. Pain with overhead reaching, pushing, or pulling. Difficulty lifting heavy loads. Inability to sustain repetitive shoulder activities. Difficulty with dressing, particularly putting a shirt on over the head.
PROTECTION PHASE Control Inflammation and Promote Healing  Modalities | Cross-fiber massage Patient Education Maintain Integrity and Mobility of Soft Tissues  PROM, AAROM at pain free ranges | Multiple-angle setting | Stabilization exercises (rot cuff, biceps, scapular ms) Control Pain and Maintain Joint Integrity  Pendulum, grade II distraction and oscillations Develop Support in Related Regions  Postural awareness | Correction techniques | Supportive techniques (strapping, taping, tactile cues, mirrors)
CONTROLLED MOTION PHASE Patient Education Develop Strong, Mobile Tissues  Cross-fiber massage or friction massage | Manual techniques | Isometric contractions at several positions | Self- administer massage and isoms Modify Joint Tracking and Mobility  Mobilization with movement Develop Balance in Length and Strength of Shoulder Girdle Muscles  Stretching, strengthen and train scapulothoracic ms and rot cuff ms. Develop Muscular Stabilization and Endurance  Alternating isoms of scapular ms in open-chain positions | Scapular and GH pattern combination | Closed-chain stabilization | Muscular edurance progression Progress Shoulder Function  Increase coordination, balance in strength, and endurance of should and scapular ms
RETURN TO FUNCTION PHASE Increase Muscular Endurance  To increase muscular endurance, repetitive loading of the defined patterns is increased from 3 minutes to 5 minutes. Develop Quick Motor Responses to Imposed Stresses  Apply the stabilization exercises with increased speed with shorter durations and faster transitions between the applied forces.  Plyometric training in both open-chain and closed-chain patterns Progress Functional Training  Eccentric training is progressed to maximum load | desired functional activities are stimulated | Patient involved in assessing performance

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2025 Caribbean Examinations Council CAPE Merit List
byCaribbean Examinations Council
 

Shoulder and Shoulder Girdle: Anatomy and Function

  • 1.
    SHOULDER AND SHOULDERGIRDLE Orthopedic and Sports 2
  • 2.
    The shoulder regionis a complex of 20 muscles, three bony articulations, and three soft tissue moving surfaces (functional joints) that permit the greatest mobility of any joint area found in the body. The primary purpose of the shoulder is to put the hand in a position for function
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    MANUBRIUM (STERNUM) Secures theupper extremity to the axial skeleton Superior: Sternal notch or jugular notch Lateral: Clavicular facets (attachment of the first rib)
  • 6.
    CLAVICLE Strut bone –lateral strut to the scapula and humerus S-shaped, with forward convexity at the sternal end (to clear the brachial plexus & UE vascular bundle) and forward concavity at the humeral/acromial end Resting 20° to the frontal plane
  • 7.
    SCAPULA Flat, triangular-shaped bone 5-6cm/2-3 finger-width from the spinous processes Landmark: T2-T7 spinous process Dual function: (1) attachment of muscles controlling the GH joint, and (2) provide stable base from which the GH joint can function
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    HUMERUS Head of thehumerus forms the GH jt with the glenoid fossa. 1/3 or ½ of a sphere Humeral head
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    SCAPULOTHORACIC JOINT A functionaljoint BUT Not A “TRUE JOINT” Functions: Increase the ROM of the shoulder (greater reach) Maintain favorable length-tension relationship for the deltoid muscle to function above 90º of GH elevation Provide GH stability through maintained glenoid and humeral head alignment Providing injury prevention through shock absorption of forces applied to the outstretched arm Permitting elevation of the body in activities (assistive device and transfers)
  • 11.
    SCAPULOTHORACIC JOINT ST JointKinematics  Scapular Elevation/Depression  Scapular Protraction/Retraction  Scapular Upward Rotation/Downward Rotation
  • 12.
    SCAPULOTHORACIC JOINT Scapulothoracic Rhythm PhaseHumerus Scapula Clavicle I 30º Abduction Setting Phase 0-5º Elevation II 40º Abduction 20º Upward rotation 10-15º Elevation III 60º Abduction 30º Upward rotation Clavicle starts to rotate posteriorly
  • 14.
    GLENOHUMERAL JOINT Ball-and-socket joint;Spheroid jt; Universal Joint Degrees of freedom: 3 DOF Little bony stability Articulation: Convex humeral head – Concave glenoid fossa (shallow, inclined) Joint relies on the surrounding soft tissue supports for stability  Mobile, however, is at the expense of structural stability
  • 16.
    GLENOHUMERAL JOINT Open-Packed Position 40°to 55° abduction, 30° horizontal adduction (scapular plane) Closed-Packed Position Full abduction, lateral rotation Capsular Pattern Lateral rotation, abduction, medial rotation
  • 17.
    GLENOHUMERAL JOINT Ligaments Ligament Position ofGreatest Jt Protection Motion it Limits Coracohumeral ligament With arm at the side Limits excessive lateral rotation Limits inferior translation of humeral head Superior GH ligament With arm at the side (0-45º) Limits anterior and inferior translation of the humeral head Middle GH ligament With the arm at the side and lower levels (up to about 45°) of abduction Limits anterior translation and lateral rotation of the humeral head Inferior glenohumeral ligament Higher levels of abduction (above 45°), with or without rotation Higher levels of abduction (above 45°), with or without rotation Anterior fibers - limit anterior humeral head translation during abduction and lateral rotation Posterior fibers - limit posterior humeral head translation during abduction and medial rotation Inferior fibers - limits abduction at 90° and provides AP All normal limitations of motion on the glenohumeral joint are due to ligamentous and passive muscle tightening. Thus, the end feels are all firm.
  • 18.
    GLENOHUMERAL JOINT Coracoacromial arch Osteoligamentous arch, formed by the coracoacromial ligament, that serve as the roof to the GH joint Subacromial space  Space between the coracoacromial arch and the GH joint  Supraspinatus muscle and tendon  Long head of the biceps tendon  Subacromial bursa  Superior capsule
  • 19.
    GLENOHUMERAL JOINT Bursae Bursa reducesfriction between two structures  Subacromial bursa  Subdeltoid Bursa
  • 21.
    GLENOHUMERAL JOINT MUSCLE GHJoint Kinematics  Flexion-extension  Abduction-adduction  Medial rotation-lateral rotation GH Joint Arthrokinematics
  • 22.
    STERNOCLAVICULAR JOINT Type ofjoint: Saddle joint, Sellar joint Degrees of freedom: 3 DOF Articulation:  Medial end of clavicle  Manubrium
  • 24.
    STERNOCLAVICULAR JOINT Open-Packed PositionArm at side Closed-Packed Position Full elevation and protraction Capsular Pattern Pain at extremes of ROM, especially horizontal adduction and full elevation
  • 26.
    STERNOCLAVICULAR JOINT Ligament Motionit limits Anterior SC ligament Limits posterior displacement of clavicle Posterior SC ligament Limits anterior displacement of clavicle Superior SC ligament Interclavicular ligament Limits upward clavicular displacement Costoclavicular ligament Limits clavicular elevation, rotation, and medial and lateral movements
  • 27.
    SC JOINT Kinematics  3DOF  Elevation/depression (30-45º/5-10º)  Protraction/retraction (15-30º)  Rotation  Posterior rotation (40-50º) – passive motion  Occurs after 90º of elevation  (-) rotation  arm motion is limited to 110º Arthrokinematics
  • 28.
    ACROMIOCLAVICULAR JOINT Type ofjoint: Plane Synovial Joint Degrees of Freedom: 3 DOF Articulation:  Acromion process  Lateral end of Clavicle
  • 29.
    ACROMIOCLAVICULAR JOINT Open-Packed PositionArm at side Closed-Packed Position 90º abduction Capsular Pattern Pain at extremes of ROM, especially horizontal adduction and full elevation
  • 32.
    ACROMIOCLAVICULAR JOINT Ligaments Ligament Motionit limits Posterior AC ligament Limits superior translation of the distal clavicle Superior AC ligament Limits inferior translation of the distal Coracoclavicular ligament • Trapezoid – restricts superior translation of the distal clavicle (1ry) • Conoid – prevents medial displacement of the sacpula
  • 33.
    ACROMIOCLAVICULAR JOINT AC JointKinematics  3 DOF of Scapular Movements  Elevation/depression  Abduction/adduction  Upward/Downward rotation Primary function at the AC joint is to allow the scapula to maintain contact with the thorax throughout its movement by providing slight adjustments in the scapular motions provided via the sternoclavicular joint.
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  • 36.
    SCAPULOHUMERAL RHYTHM Upward rotation,posterior tilting and scapular external rotation w/ shoulder elevation Synchronous motion of scapula allows the muscle moving the humerus to maintain an effective length-tension relationship and helps maintain congruency while decreasing shear forces. Upper and lower trapezius and serratus anterior creates upward rotation of the scapula. Pectoralis minor lengthening allows scapula to rotate upward, retracts, and tip posteriorly.
  • 38.
    CLAVICULAR ELEVATION ANDROTATION WITH HUMERAL MOTION First 30º of upward rotation of the scapula occurs at the SC jt. Tightening of coracoclavicular ligament, rotates the clavicle and elevates the acromial end  additional 30º of upward rotation at AC jt.
  • 39.
    EXTERNAL ROTATION OFHUMERUS WITH ELEVATION Humerus externally rotates to allow clearance of greater tubercle to the acromion/coracoacromial arch.
  • 40.
    DELTOID-SHORT ROTATOR CUFFAND SUPRASPINATUS Deltoid – upward translation of the humerus, and if unopposed, it leads to impingement of soft tissues in the subacromial space. In order to prevent it,  Infraspinatus, teres minor, and subscapularis (ITS) produces stabilizing compression and downward translation of the humerus  Deltoid and ITS actions  balance forces that elevate the humerus and control humeral head  Supraspinatus has significant stabilizing, compressive, and slight upward translation.  Interruption of the coordinated function may lead to tissue microtrauma and shoulder complex dysfunction.
  • 41.
    REFERRED PAIN ANDNERVE INJURY Common Sources of Referred Pain in the shoulder  Cervical Spine  C3-C4 or C4-C5 segments  C4 or C5 nn roots  Referred pain  C4 dermatome  Trapezius  tip of the shoulder  C5 dermatome  Deltoid region and lateral arm  Diaphragm: Pain at the upper trapezius shoulder region  Heart: Pain at the left axilla and pectoral region  Gallbladder: Pain at the tip of the shoulder and scapular region
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    GH JOINT ARTHRITIS AcutePhase Pain, muscle guarding, limited ER & Abd. Pain radiates to the elbow Sleep disturbance Tenderness is elicited by palpating in the sulcus Subacute Phase Chronic Phase Capsular tightness (ERABIR), limited joint play Pain at end of range Progressive GH joint capsule restriction Loss of function Pain localized at deltoid region
  • 46.
    IDIOPATHIC FROZEN SHOULDER StageDuration Characteristics Stage 1 Pre-freezing <3 months Gradual onset of pain with movement and persistent at night Loss of ER motion Intact rotator cuff strength Stage 2 Freezing 3-9 months Persistent and more intense pain at rest Motion is limited in all direction (-) restoration from intra-articular injections Stage 3 Frozen 9-15 months Pain on movement Significant adhesions  LOM Excessive scapulothoracic movement Atrophy: deltoid, rot cuff, biceps, and triceps Stage 4 Thawing 15-24 months Minimal pain Significant capsular restrictions Gradual improvement of motion Some never regain normal ROM
  • 48.
    COMMON IMPAIRMENTS OFSTRUCTURE AND FUNCTIONS Night pain and disturbed sleep during acute flares Pain on motion and often at rest during acute flares Mobility: decreased joint play and ROM, usually limiting external rotation and abduction with some limitation of internal rotation and flexion Posture: possible faulty postural compensations with protracted and anteriorly tilted scapula, rounded shoulders, or guarding the painful shoulder in a position of scapula elevation and arm adduction
  • 49.
    COMMON IMPAIRMENTS OFSTRUCTURE AND FUNCTIONS Decreased arm swing during gait Muscle performance: general muscle weakness and poor endurance in the GH muscles with overuse of the scapular muscles leading to pain in the trapezius, levator scapulae, and posterior cervical muscles Increased scapulothoracic motion during arm movements to compensate for limited GH mobility
  • 50.
    COMMON ACTIVITY LIMITATIONSAND PARTICIPATION RESTRICTIONS Inability to reach overhead, behind head, out to the side, and behind back leading to difficulty dressing (putting on a jacket or coat or in the case of women, fastening undergarments behind their back), reaching hand into back pocket of pants (to retrieve wallet), reaching out a car window (to use an ATM machine), self-grooming (combing hair, brushing teeth, washing face), and bringing eating utensils to the mouth Difficulty lifting heavy objects above shoulder level Limited ability to sustain repetitive activities
  • 51.
    MANAGEMENT: PROTECTION PHASE Educatethe Patient  Activity modifications, stages of healing, Control Pain, Edema, and Muscle Guarding  Immobilization, passive or assisted motion, oscillation techniques, tissue mobilization
  • 52.
    MANAGEMENT Maintain Soft Tissueand Joint Integrity and Mobility  PROM (pain free), Grade I-II distraction and glides, pendulum exercises, gentle muscle setting Maintain Integrity and Function of Associated Regions  Prevent complications by adding hand exercises, keep distal joints active and mobile, (+) edema  hand elevation, and ROM, mobilization of the cervical region
  • 53.
    MANAGEMENT: CONTROLLED MOTIONPHASE Control Pain, Edema, Joint Effusion  Functional activities, ROM Progressively Increase Joint and Soft Tissue Mobility  Passive joint mobilization techniques (grade III sustained or grade III and IV oscillations), self- mobilization techniques, manual stretching, self-stretching exercises Inhibit Muscle Spasm and Correct Faulty Mechanics  Grade I and II oscillation, sustained caudal glide joint techniques, protected weight bearing, IR/ER strengthening, movement retraining
  • 54.
    MANAGEMENT: CONTROLLED MOTIONPHASE Improve Joint Tracking  Shoulder mobilization with movement Improve Muscle Performance  Manual techniques, stretches, and strengthening exercises are initiated to correct muscle length or strength imbalances, followed by an emphasis on developing active control of weak musculature.  Exercises to manage faulty spinal posture.  Active ROM of all shoulder motions daily and return to functional activities to the extent tolerated.
  • 55.
    MANAGEMENT: RETURN TOFUNCTION Progressively Increase Flexibility and Strength  Stretching and strengthening exercises, as tolerated  Emphasis of treatment is on maintaining correct mechanics, safe progressions, and exercise strategies for return to function.  (+) capsular restriction  vigorous manual stretching and joint mobilization Prepare for Functional Demands  Exercises must and are progressed to replicate these demands (work, sports, etc.)
  • 56.
    AC AND SCJOINT PATHOLOGIES Pathologies Etiology of Symptoms Overuse Syndrome Repeated stressful joint movements or repeated diagonal extension, adduction, and IR Subluxation or Dislocation FOOSH  overstretching of ligament  permanent joint hypermobility Hypomobility Decreased clavicular mobility may occur with SC joint OA and may contribute to TOS by compromising the space available for the neuromuscular bundle as it courses between the clavicle and first rib
  • 57.
    COMMON IMPAIRMENTS OFSTRUCTURE AND FUNCTION Pain localized to the involved joint or ligament. Painful arc toward the end-range of shoulder elevation. Pain with shoulder horizontal adduction or abduction. Hypermobility if trauma or overuse is involved. Hypomobility if sustained posture, arthritis, or immobility is involved.
  • 58.
    COMMON ACTIVITY LIMITATIONSAND PARTICIPATION RESTRICTIONS Limited ability to sustain repeated forceful movements of the arm, such as with grinding, packing, assembly, and construction work Inability to reach overhead or perform repetitive overhead activities without pain.
  • 59.
    NONOPERATIVE MANAGEMENT OFAC OR SC JOINT STRAIN OR HYPERMOBILITY Minimize joint loading by supporting the weight of the arm with a sling. Cross-fiber massage to the capsule or ligaments. Maintain ROM of the GH joint and scapulothoracic articulation. Instruction in self-application of cross-fiber massage if joint symptoms occur after excessive activity. Increase strength of shoulder complex, trunk, and legs. Gradually return to functional activities.
  • 60.
    GLENOHUMERAL JOINT SURGERY ANDPOSTOPERATIVE MANAGEMENT
  • 61.
    GOALS OF THESURGICAL PROCEDURE Relieve pain Improve shoulder mobility or stability Restore or improve strength and functional use of the upper extremity.
  • 62.
    Total Shoulder Arthroplasty (TSA) ReversedTSA Hemiarthroplasty (+) loss or thinning of the articular cartilage of the head of the humerus and the posterior portion of the glenoid fossa. (+) Chronic deficiency of the rotator cuff mechanism. (+) deterioration of the articular surface and underlying bone of the humeral head, but glenoid fossa is intact. Intact rotator cuff (90-95%)
  • 63.
    GLENOHUMERAL ARTHROPLASTY Implant design,materials, and fixation  Unconstrained design  MC used | Small, shallow glenoid component | Greatest freedom | Indicated when Rot, Cuff is intact or can be repaired  Semiconstrained  Large glenoid component that is hooded or cup-shaped | Some degree of stability | Indicated when erosion of scapula can be compensated by reaming the fossa | Functional rot cuff  Reverse ball and socket  Small humeral socket that slides on a larger ball-shaped glenoid component | Moderate stability with rot cuff mobility | Alternative approach  Constrained  Fixed fulcrum, ball and socket designs | Greatest stability, dec mobility | Rarely
  • 64.
    SHOULDER ARTHROPLASTY PROCEDURE Anteriorapproach using a deltopectoral incision that extends from the AC joint to the deltoid insertion for adequate surgical exposure. Release (tenotomy) of the subscapularis tendon from its proximal attachment on the lesser tuberosity. Anterior capsulotomy Exposure of the humeral head for a humeral osteotomy Preparation of the humeral canal for insertion of the prosthetic implant. Glenoid fossa is either débrided or contoured Reattachment of subscapularis mm
  • 65.
    COMPLICATIONS TSA complications arelow Incidence tends to be higher in patients with deficient rotator cuff mechanism
  • 66.
    POSTOPERATIVE MANAGEMENT The goals,components, and rate of progression are influenced by the preoperative and postoperative integrity of the rotator cuff mechanism.  Progression of intact rotator cuff > rotatory cuff w/ deficiency Intraoperative ROM determines the goals for safe, stable postoperative ROM. Emphasize an erect sitting or standing posture during elevation of the arm.
  • 67.
    POSTOPERATIVE MANAGEMENT Immobilization andPostoperative Positioning  (+) rotator cuff repair or soft tissue reconstruction – wear shoulder sling for 4-6 weeks
  • 68.
    POSTOPERATIVE MANAGEMENT Exercise progression TSA  Phase 1: Weeks 0-4  Phase 2: Weeks 4-12  Phase 3: Weeks 12+  rTSA  Phase 1: Weeks 0-6  Phase 2: Weeks 6-12 or 16  Phase 3: Weeks 12+ or 16+ Table 17.2 Comparison of Exercise Guidelines and Precautions Following TSA and rTSA
  • 69.
    MAXIMUM PROTECTION PHASE(0 TO 4/6 WEEKS) Patient education, pain control and initiation of ROM Goals and Interventions  Control pain and inflammation  Sling or splint, analgesics and anti-inflammatory medications, cryotherapy after exercise  Maintain mobility of adjacent joints  Active ROM (AROM) spine, scapular, hand, wrist and elbow  Restore shoulder mobility  PROM (scapular plane elevation), pendulum exercises, progress: self-assisted shoulder ROM, self-assisted reaching movements | by 4 weeks active shoulder ROM  Minimize muscle inhibition, guarding, & atrophy  Gentle ms setting, scapular stabilization (NWB, target traps and SA)
  • 70.
    MAXIMUM PROTECTION PHASE(0 TO 4/6 WEEKS) Criteria for progress  ROM  At least: 90º passive elevation, 45º ER, and 70º IR in the plane of scapula  Pain  No pain during resisted, isometric internal rotation  Skill  Ability to perform waist-level ADLs without pain  rTSA  Tolerance of assisted ROM, ability to isometrically activate deltoid and periscapular muscles @ scapular plane.
  • 71.
    MODERATE PROTECTION PHASE(4/6 TO 12/16 WEEKS) Focuses on gradually establishing active (unassisted) control, dynamic stability, and strength of the shoulder while continuing to increase ROM. Goals and Intervention  Continue to increase shoulder ROM  Develop active control and dynamic stability and improve performance of the shoulder  Pain free, low-intensity resisted isometrics of shoulder muscles  Dynamic resistance exercises for the scapula and shoulder muscles (0-90º elevation, supine  sitting).  UE endurance training
  • 72.
    MODERATE PROTECTION PHASE(4/6 TO 12/16 WEEKS) Criteria to Progress  Full, passive ROM of the shoulder (intraoperative ROM) or pain-free passive or assited shoulder flexion to 130- 140º and abd of 120º  60º ER and 70º IR in the plane of scapula  Active, antigravity elevation of the arm to at least 100° to 120° in the plane of the scapula  Deltoid: grade 4/5 MMT
  • 73.
    MINIMUM PROTECTION PHASE(12+ OR 16+ WEEKS) Focuses on pain-free strengthening of the shoulder muscles for dynamic stability and functional use of the upper extremity for progressively more demanding tasks. Goals and Intervention  Continue to improve or maintain shoulder mobility  End-range self-stretching | Grade III joint mobilization | Self-mobilization  Continue to improve neuromuscular control and muscle performance of the shoulder  Pain-free, low-load, high-repetition progressive resistive exercise | Replicate functional tasks | Closed chain, restricted shoulder exercises | Lifting, carrying, pushing or pulling activities  Return to most functional activities  Use UE for more advanced functional activities | Swimming, golf (recreational activities) | Activity modification, especially on high- demand/-impact activities
  • 74.
    PAINFUL SHOULDER SYNDROMES(ROTATOR CUFF DISEASE AND TENDINOPATHIES): NONOPERATIVE MANAGEMENT
  • 75.
    RELATED PATHOLOGIES ANDETIOLOGY OF SYMPTOMS Intrinsic Impingement  Rotator Cuff Extrinsic Impingement  Mechanical Compression  Primary extrinsic impingement  E.g. Acromial variations  Secondary intrinsic impingement  Hypermobility or instability  Internal extrinsic impingement  Throwing athletes shoulder position impinge supraspinatus tendon bet head and labrum
  • 77.
    RELATED PATHOLOGIES ANDETIOLOGY OF SYMPTOMS Tendonitis  Supraspinatus tendonitis  Infraspinatus tendonitis  Bicipital tendonitis  Bursitis
  • 79.
    COMMON IMPAIRMENTS OF STRUCTUREAND FUNCTION Impaired posture and muscle imbalances Decreased thoracic range of motion Rotator cuff overuse and fatigue Weakness secondary to neuropathy Hypomobile posterior GH joint capsule
  • 80.
    COMMON ACTIVITY LIMITATIONSAND PARTICIPATION RESTRICTIONS In the acute stages, pain may interfere with sleep, particularly when rolling onto the involved shoulder. Pain with overhead reaching, pushing, or pulling. Difficulty lifting heavy loads. Inability to sustain repetitive shoulder activities. Difficulty with dressing, particularly putting a shirt on over the head.
  • 81.
    PROTECTION PHASE Control Inflammationand Promote Healing  Modalities | Cross-fiber massage Patient Education Maintain Integrity and Mobility of Soft Tissues  PROM, AAROM at pain free ranges | Multiple-angle setting | Stabilization exercises (rot cuff, biceps, scapular ms) Control Pain and Maintain Joint Integrity  Pendulum, grade II distraction and oscillations Develop Support in Related Regions  Postural awareness | Correction techniques | Supportive techniques (strapping, taping, tactile cues, mirrors)
  • 82.
    CONTROLLED MOTION PHASE PatientEducation Develop Strong, Mobile Tissues  Cross-fiber massage or friction massage | Manual techniques | Isometric contractions at several positions | Self- administer massage and isoms Modify Joint Tracking and Mobility  Mobilization with movement Develop Balance in Length and Strength of Shoulder Girdle Muscles  Stretching, strengthen and train scapulothoracic ms and rot cuff ms. Develop Muscular Stabilization and Endurance  Alternating isoms of scapular ms in open-chain positions | Scapular and GH pattern combination | Closed-chain stabilization | Muscular edurance progression Progress Shoulder Function  Increase coordination, balance in strength, and endurance of should and scapular ms
  • 83.
    RETURN TO FUNCTIONPHASE Increase Muscular Endurance  To increase muscular endurance, repetitive loading of the defined patterns is increased from 3 minutes to 5 minutes. Develop Quick Motor Responses to Imposed Stresses  Apply the stabilization exercises with increased speed with shorter durations and faster transitions between the applied forces.  Plyometric training in both open-chain and closed-chain patterns Progress Functional Training  Eccentric training is progressed to maximum load | desired functional activities are stimulated | Patient involved in assessing performance

Editor's Notes

  • #2 The shoulder complex not only provides a wide range of positions for hand placement, but it also stabilizers the upper extremity for hand motions.
  • #10 Maintain favorable length-tension relationship for the deltoid muscle to function above 90º of GH elevation, allowing better shoulder joint stability throughout a greater ROM Provide GH stability through maintained glenoid and humeral head alignment for work in overhead position Permitting elevation of the body in activities such as walking with crutches or performing seated push-ups during transfers by persons with a disability
  • #19 Bursae Bursa reduces friction between two structures Subacromial bursa - is located between the supraspinatus tendon and the coracoacromial arch Protect the supraspinatus and allow for smooth tendon movement during shoulder motion Subdeltoid Bursa - between the deltoid muscle and the supraspinatus tendon and humeral head
  • #22 The fibrocartilaginous articular disc function Hinge for motion Stability: reduce sliding over the manubrium Stability: increase congruency between jt surfaces Shock absorption
  • #25 Ligament Motion it limits Anterior SC ligament Limits posterior displacement of clavicle Posterior SC ligament Limits anterior displacement of clavicle Superior SC ligament Interclavicular ligament Limits upward clavicular displacement Costoclavicular ligament Limits clavicular elevation, rotation, and medial and lateral movements
  • #30 .If a step deformity occurs, this ligament has been torn
  • #32 Coracoclavicular ligament – primary support of the acromioclavicular ligament
  • #33 Whereas the sternoclavicular joint provides for extensive clavicular motion and guides the general path of the scapula, the acromioclavicular joint motions are more subtle and provide for key but small adjustments of the scapula to allow continuity between the scapula and thorax during scapular movements
  • #41 Kher sign Levine’s sign Brachial plexus in the thoracic outlet. Common sites for compression are the scalene triangle and the costoclavicular space and under the coracoid process and pectoralis minor muscle. Suprascapular nerve in the suprascapular notch. This injury occurs from either direct compression or from nerve stretch, such as when carrying a heavy book bag over the shoulder. Radial nerve in the axilla. Compression occurs from continual pressure, such as when leaning on axillary crutches
  • #51 Educate the Patient ■ Provide information about what to expect regarding the stages of healing. ■ Instruct patient in safe motions and activity modifications that minimize joint stress. Control Pain, Edema, and Muscle Guarding ■ The joint may be immobilized in a sling to provide rest and minimize pain. ■ Intermittent periods of passive or assisted motion within the pain free/protected ROM and gentle joint oscillation techniques to minimize further adhesions are initiated as soon as the patient tolerates movement. ■ Gentle soft tissue mobilization of the cervical and periscapular muscles may improve patient comfort and minimize protective guarding, as may cervical ROM and/or cervical grade I or II passive intervertebral mobilizations.
  • #52 Educate the Patient ■ Provide information about what to expect regarding the stages of healing. ■ Instruct patient in safe motions and activity modifications that minimize joint stress. Control Pain, Edema, and Muscle Guarding ■ The joint may be immobilized in a sling to provide rest and minimize pain. ■ Intermittent periods of passive or assisted motion within the pain free/protected ROM and gentle joint oscillation techniques to minimize further adhesions are initiated as soon as the patient tolerates movement. ■ Gentle soft tissue mobilization of the cervical and periscapular muscles may improve patient comfort and minimize protective guarding, as may cervical ROM and/or cervical grade I or II passive intervertebral mobilizations.
  • #53 Protected weight bearing, such as leaning hands against a wall or on a table, to stimulate rotator cuff and scapula stabilizer co-contraction and improve synovial fluid movement through hyaline cartilage compression. Techniques are progressed by gentle rocking forward/backward and side to side, moving from bilateral to unilateral, increasing the angle of the joint, or adding perturbations.
  • #60 Severe deterioration of one or both surfaces of the GH joint or an acute or nonunion fracture of the proximal humerus often must be managed with surgical intervention. Underlying pathologies that cause advanced joint destruction include late-stage OA, RA, traumatic arthritis, cuff tear arthropathy, and osteonecrosis (avascular necrosis) of the head of the humerus. The most common surgical procedure used to treat advanced shoulder joint pathology is GH arthroplasty, often simply referred to as shoulder arthroplasty.34 In rare situations, arthrodesis (surgical ankylosis) of the GH joint may be necessary as an alternative to arthroplasty or as a salvage procedure. GH arthroplasty Total shoulder arthroplasty hemireplacement arthroplasty, reversed totals shoulder arthroplasty
  • #61 The extent to which these goals are achieved is predicated on the patient’s participation in postoperative rehabilitation, the distinguishing features and severity of the underlying pathology; the prosthetic design and surgical techniques; the integrity of the rotator cuff mechanism and other soft tissues; and the age, overall health, and anticipated activity level of the patient.
  • #64 Complications The incidence of complications after TSA tends to be higher in patients with a deficient rotator cuff mechanism, osteoporosis, or a history of chronic GH joint instability. Aside from medical complications such as infection or a deep vein thrombosis, complications specific to shoulder arthroplasty
  • #66 Special Considerations
  • #71 stability, and strength of the shoulder while continuing to increase ROM
  • #72 stability, and strength of the shoulder while continuing to increase ROM
  • #74 Impingement syndrome, this common and multifactorial cause of pain was originally believed to be the result of mechanical compression and irritation of suprahumeral tissues.
  • #75 Intrinsic conditions typically involve the deep articular side of the tendons and may progress to articular-side rotator cuff tears, seen most often in those older than 40 years of age Extrinsic impingement is believed to occur as a result of mechanical compression of the rotator cuff against the anteroinferior one-third of the acromion in the suprahumeral space during arm elevation (Fig. 17.15). Tendon compression is believed to result from anatomical or biomechanical factors that decrease the physical dimensions of the suprahumeral space. Internal impingement is a type of extrinsic impingement that occurs in a position of elevation, horizontal abduction, and maximum external rotation, primarily in throwing athletes
  • #77 Intrinsic conditions typically involve the deep articular side of the tendons and may progress to articular-side rotator cuff tears, seen most often in those older than 40 years of age
  • #79 Increased thoracic kyphosis, forward head, and protracted and forward-tilted scapula | With this posture, the pectoralis minor, levator scapulae, and shoulder internal rotators may become tight, and the external rotators of the shoulder and upward rotators of the scapula may test weak and have poor muscular endurance. Thoracic extension is a component motion that is needed for full overhead reaching. | e decreased thoracic spine mobility leading to faulty scapulothoracic mechanics and altered muscle activity If the rotator cuff musculature or long head of the biceps fatigue from overuse, they no longer provide the dynamic stabilizing, compressive, and translational forces that support the joint and control healthy joint mechanics. | Without this dynamic stability, the tissues in the subacromial space may become impinged as a result of faulty joint mechanics | There is also a relationship between muscle fatigue and joint position sense in the shoulder that may play a role in impaired performance in repetitive overhead activities Muscle weakness may be related to compromised nerve function. Long thoracic nerve palsy has been associated with faulty scapular mechanics due to serratus anterior muscle weakness Loss of extensibility in the posterior GH joint capsule may negatively alter humeral head translations. Increased superior translations during arm elevation are reported in studies that have experimentally tightened the posterior capsule, an effect that would decrease the available suprahumeral space.
  • #81 Symptom Management
  • #82 Emphasis shifts to progressive movements within safe limits and using proper mechanics while the tissues heal
  • #83 Specificity of training toward the desired functional outcomes begins as soon as the patient has developed control of posture and can perform the basic components of their desired activities without exacerbating the symptoms. ■ Eccentric training is progressed to maximum load. ■ Desired functional activities are simulated—first under controlled conditions, then under progressively challenging conditions using acceleration/deceleration drills. ■ The patient is involved in assessing performance in terms of safety, symptom provocation, postural control, and ease of execution and then practices adaptations to correct any identified problems